Predicting Survival

Predicting Survival in Oldest Old People

In a cohort of oldest old people (over age 85), slow gait speed and Instrumental Activities of Daily Living disability are both predictors of survival.

Abstract 
Objective 
Measures of physical performance are regarded as useful objective clinical tools to estimate survival in elderly people. However, oldest old people, aged 85 years or more, are underrepresented in earlier studies and frequently unable to perform functional tests. We studied the association of gait speed and survival in a cohort of oldest old people and the association of Instrumental Activities of Daily Living by questionnaire and survival as an alternative prognostic marker of survival.

Methods 
The Leiden 85-plus Study was used, a prospective population-based study with a follow-up period of 12 years. The study comprised 599 participants all aged 85 years at baseline. Survival rate was the measurement. Results At age 85 years, 73 participants (12.2%) did not perform the walking test. Gait speed faster than 0.8 m/s was present in only 48 participants (9%), and gait speed faster than 1.0 m/s was present in 10 participants (1.9%). Risk for all-cause mortality was higher in participants with slow gait speed after 2 and 12 years of follow-up (hazard ratio [HR], 2.66; 95% confidence interval [CI], 1.49-4.75; P<.001; and HR, 2.04; 95% CI, 1.61-2.59; P=.100, respectively). Significance was lost after adjustment for common confounders. Poor Instrumental Activities of Daily Living ability was associated with an increased risk of mortality after 2 and 12 years of follow-up (HR, 6.11; 95% CI, 3.44-10.87; P<.001; and HR, 2.75; 95% CI, 2.22-3.40; P<.001, respectively). Adjustment for possible confounders attenuated the relation but remained significant.

Conclusions
The cutoff points for gait speed in oldest old people need to be reevaluated. In oldest old people aged 85 years, slow gait speed (≤0.40 m/s in women and ≤0.45 m/s in men) and Instrumental Activities of Daily Living disability are both predictors of survival. Assessment of Instrumental Activities of Daily Living could be a better tool for short- and long-term prognostication of survival in oldest old people.

--To read this article in its entirety, please visit our website.

--Diana G. Taekema, MD, PhD, J. Gussekloo, MD, PhD, Rudi G.J. Westendorp, MD, PhD, Anton J.M. de Craen, PhD, Andrea B. Maier, MD, PhD 

--This article originally appeared in the December 2012 issue of The American Journal of Medicine.

Searching for the Holy Grail

The Search for the Holy Grail: Doing More with Less

In the movie Indiana Jones and the Holy Grail when Jones and others are confronted with numerous cups, only one of which is the Grail, the advice of the old Knight Templar is to “choose wisely.” In the movie, the cup that is least appealing is the Grail, and failure to make the right choice leads to death.

Likewise, the failure of physicians and patients to make the right choices puts the financial well-being of the United States at risk. Physicians are confronted with numerous tests or procedures that can be applied to our patients. We frequently do not choose wisely because we do not consider the cost in relationship to the benefit to the patient. Rather, physicians tend to select what is most expedient or new or likely to be of financial benefit to them. Approximately 18% of the US gross domestic product was spent on healthcare in 2011. It is estimated that 21% to 34% of this expenditure is wasted.1 Overtesting accounts for $210 billion of the $2.2 trillion the United States spends on healthcare each year.2 Options to control these costs are limited. One approach is to reduce reimbursement to providers and hospitals for the care being provided. Another and more appealing alternative is to reduce the waste.

The American Board of Internal Medicine Foundation has created Choosing Wisely, in which the American Board of Internal Medicine has partnered with 9 other societies to help physicians better manage our healthcare dollars. The stated goal is “while managing the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources”.3 Each of the societies has developed recommendations for certain disorders in which cost-effective decisions can be made between the patient and the physician. All of these recommendations can be found on choosingwisely.org.

--To read this article in its entirety, please visit our website.

--Thomas Boyer, MD

--This article originally appeared in the December 2012 issue of The American Journal of Medicine.

Related article: Tailoring Colorectal Cancer Screening by Considering Risk of Advanced Proximal Neoplasia

The Risk of Pill Cutter Sharing

The most frequent cause of secondary adrenal insufficiency is the prolonged exposure to exogenous glucocorticoids (GCs).(1) The source of GCs is most often obvious (oral or parenteral, or even inhaled), but it may be occasionally more difficult to identify, as GCs may be found in “traditional” or “alternative” medicines.(2) We describe here the case of a patient with secondary adrenal insufficiency due to using the same pill cutter for her medications and her dog's prednisone.

A 45-year-old woman with history of depression presented to her internist complaining of 4 weeks of decreased appetite, nausea, weakness, and 4-kg weight loss. Symptoms had started about 1 week after her dog died...

The patient denied ever taking oral, topical, or parenteral GCs or any alternative medicine preparation. Her dog had a history of Addison's disease and had been on prednisone for the past 6 years. She had been administering prednisone to the pet by breaking twice daily a 5-mg prednisone tablet into quarters, using a pill cutter. Over these years, she had frequently used the same pill cutter to cut her own antidepressant pills.

--To read this article in its entirety, please visit our website.

--Sritika Thapa, MD and Roberto Salvatori, MD

--This article originally appeared in the November 2012 issue of The American Journal of Medicine.

Surviving Bariatric Surgery

An Uncommon Option for Surviving Bariatric Surgery: Regaining Weight!

In November 2011, a 32-year-old woman was admitted to the intensive care unit for acute respiratory failure. She had felt well consistently until February (including 2 pregnancies), when she underwent a noncomplicated sleeve gastrectomy for obesity (body mass index, 47 kg/m2). Her weight gain, unrelated to any endocrine disease, had started with adolescence and was resistant to all attempts to lose weight. One month after bariatric surgery and a loss of 20 kg, she had a first episode of constant and diffuse abdominal pain with slightly increased plasma concentration of lipase, and pancreatitis was diagnosed. Recurrent monthly vomiting episodes occurred later with abdominal and leg pains unrelated to her menstrual cycle. To counter postoperative deficiencies, she was fully supplemented with all vitamins. She had been treated regularly with analgesic drugs in an attempt to relieve erratic pain. Three weeks before admission, leg pains intensified, and tetraparesis developed over 2 days. On admission (6 months after surgery), her body mass index was 21 kg/m2 and heart rate was 135 beats/min. She had tetraparesis with diffuse allodynia and paresthesias, facial diplegia, and swallowing disorders with alveolar hypoventilation requiring mechanical ventilation.

Laboratory test results showed hypokalemia (2.6 mmol/L), hyponatremia (134 mmol/L), and moderately elevated liver enzymes (alanine aminotransferase 79 UI/L and aspartate aminotransferase 47 UI/L) without cholestasis. Renal function, blood counts, hemostasis, and Lyme serology were normal, as well as dosages of vitamins. Repeated cerebrospinal fluid examinations showed normal protein concentration without cells. Electromyography was compatible with severe motor axonal polyneuropathy. Magnetic resonance imaging showed focal cervical hyperintensity compatible with myelitis. Electroencephalography was normal.

Supportive care was given, and immunoglobulins were infused to treat a possible Guillain-Barre syndrome. No improvement was noted during the first few days.

--To read this article in its entirety, please visit our website.

-- François Danion, Max Guillot, MD, Vincent Castelain, MD, PhD, Hervé Puy, MD, PhD, Jean-Charles Deybach, MD, PhD, Francis Schneider, MD, PhD

--This article originally appeared in the November 2012 issue of The American Journal of Medicine.

Computerized Patient Education

Using Animated Computer-generated Text and Graphics to Depict the Risks and Benefits of Medical Treatment

Computer-animated depictions of risks and benefits offer an effective means to describe medical risk/benefit statistics. Understanding and satisfaction were significantly better when the format matched the patient’s preference for message delivery.

 Abstract 
Objective 
Conventional print materials for presenting risks and benefits of treatment are often difficult to understand. This study was undertaken to evaluate and compare subjects' understanding and perceptions of risks and benefits presented using animated computerized text and graphics.

Methods
Adult subjects were randomized to receive identical risk/benefit information regarding taking statins that was presented on an iPad (Apple Corp, Cupertino, Calif) in 1 of 4 different animated formats: text/numbers, pie chart, bar graph, and pictograph. Subjects completed a questionnaire regarding their preferences and perceptions of the message delivery together with their understanding of the information. Health literacy, numeracy, and need for cognition were measured using validated instruments.

Results 
There were no differences in subject understanding based on the different formats. However, significantly more subjects preferred graphs (82.5%) compared with text (17.5%, P<.001). Specifically, subjects preferred pictographs (32.0%) and bar graphs (31.0%) over pie charts (19.5%) and text (17.5%). Subjects whose preference for message delivery matched their randomly assigned format (preference match) had significantly greater understanding and satisfaction compared with those assigned to something other than their preference.

Conclusions 
Results showed that computer-animated depictions of risks and benefits offer an effective means to describe medical risk/benefit statistics. That understanding and satisfaction were significantly better when the format matched the individual's preference for message delivery is important and reinforces the value of “tailoring” information to the individual's needs and preferences.

 --To read this article in its entirety, please visit our website.

 -- Alan R. Tait, PhD, Terri Voepel-Lewis, MSN, RN, Colleen Brennan-Martinez, BSN, MS, Maureen McGonegal, BA, Robert Levine, MD

 --This article originally appeared in the November 2012 issue of The American Journal of Medicine.

US Health Care in 2050

The Anatomy and Physiology of the US Health Care System in 2050? An Exercise in Prognostication, Fantasy, and Hope

The debate concerning the appropriate structure for the American medical system goes on. Almost every day, one reads a newspaper or magazine article focusing on the strengths and flaws of our health care network. Should we imitate successful systems elsewhere in the world? How can we insure all of our citizens without bankrupting the economy? How many physicians, nurses, and hospitals do we need and how many will we need in the future? These are just some of the questions that constantly bombard us. Like all physicians in the US, we have given these questions and many others considerable thought, which we will now share with the readers of The American Journal of Medicine. These are our own personal ideas and do not reflect the official attitudes or positions of the Journal, Elsevier, any political party, or the University of Arizona.

We anticipate that the current trend towards central control of medical care will continue, and that by 2050, most physicians will work for a health care system such as the one being formed by our university health care network here in Tucson.

Accountable care organizations involving community hospitals such as Tucson Medical Center already have been formed with community doctors and their Medicare patients. These will expand to incorporate more primary care and specialty physicians, along with patients outside of Medicare age.

Individual practitioners and small groups of physicians will gradually disappear, with large numbers of doctors working for the local or regional health system. Centralization will be focused in local entities rather than in Washington, DC or individual state capitals. Physicians will be salaried by these large health networks, with incentives given for productivity and performance.

The networks will contain many components, for example, inpatient and rehabilitation hospitals, outpatient clinics, ambulatory surgical and imaging centers, as well as satellite outpatient clinics and hospitals in outlying areas. The emergency medical system will be a patchwork of state, local community, and private entities that will work closely with the large health systems. Smaller cities may have only one health care network while major urban centers may contain a number of these integrated systems. It also is possible that some of the larger networks will have insurance companies embedded in their structure. Duty hours will be strictly regulated for both trainees and full-time employees.

Most, if not all, Americans will have some form of health insurance, with many still having coverage tied to employment. However, many individuals will receive insurance from regional or federal plans paid for, in part, by state and federal taxes.

--To read this article in its entirety, please visit our website.

--Joseph S. Alpert and Eve Shapiro

--This article originally appeared in the December 2012 issue of The American Journal of Medicine.

MI Risk & Antioxidants

Total Antioxidant Capacity from Diet and Risk of Myocardial Infarction: A Prospective Cohort of Women

There are no previous studies investigating the effect of all dietary antioxidants in relation to myocardial infarction. The total antioxidant capacity of diet takes into account all antioxidants and synergistic effects between them. The aim of this study was to examine how total antioxidant capacity of diet and antioxidant-containing foods were associated with incident myocardial infarction among middle-aged and elderly women.

In the population-based prospective Swedish Mammography Cohort of 49-83-year-old women, 32,561 were cardiovascular disease-free at baseline. Women completed a food-frequency questionnaire, and dietary total antioxidant capacity was calculated using oxygen radical absorbance capacity values. Information on myocardial infarction was identified from the Swedish Hospital Discharge and the Cause of Death registries. Hazard ratios (HR) and 95% confidence intervals (CI) were calculated using Cox proportional hazard models.

--To read this article in its entirety, please visit our website.

--Susanne Rautiainen, MSc, Emily B. Levitan, DrPh, Nicola Orsini, PhD, Agneta Åkesson, PhD, Ralf Morgenstern, PhD, Murray A. Mittleman, MDDrPh, Alicja Wolk, DrMedSci

--This article originally appeared in the October 2012 issue of The American Journal of Medicine.

Rethinking the Way We Eat

Back to the Future: Rethinking the Way We Eat

In 1955, with the opening of the first McDonald's in Des Plaines, Illinois, post-war America took a quantum leap into the Fast Food Era. I vividly remember my family's first trip to a McDonald's—the gleaming white tile … the bright neon sign … the space age Golden Arches… food served in a bag and consumed in the car. We watched sea gulls glide over Lake Erie and we gobbled our little burgers, bags of fries, and chocolate shakes. As we tossed our burger bags in the trash and sped off in the car, we had no idea that our lives—and the lives of millions of other Americans—would never be the same.

From foraging to farming to fast food, the human diet has evolved over millions of years. The findings reported by Rautiainen et al in this issue of The American Journal of Medicine may prompt some of us to question if our diet is better now … or just different from our ancestors'.

--To read this article in its entirety, please visit our website.

--Pamela Powers Hannley, MPH (Managing Editor, The American Journal of Medicine)

--This article originally appeared in the October 2012 issue of The American Journal of Medicine.

Dec 2012: Gait Speed & Functionality

Gait speed and functional ability give physicians longevity clues regarding their geriatric patients. Editor-in-chief Dr. Joseph S. Alpert reviews new geriatric research in the December 2012 issue of The American Journal of Medicine.

Lead Poisoning & Ayurvedics

Ayurvedic Remedy for Diabetes as a Cause of Lead Poisoning: A Case Report

The popularity of alternative or complementary medicine has dramatically increased over the years. These types of medicine are assumed by patients to be safe and free of side effects.

A 56-year-old man presented to the emergency department with diffuse abdominal pain of 3 months' duration, decreased oral intake, and constipation. Laboratory values showed that hemoglobin had decreased to 9.7 g/dL (from a baseline of 14 g/dL 1 year previously). Levels of serum iron, transferrin, haptoglobin, vitamin B12, and folic acid were within normal limits. The anemia was normocytic, and liver enzymes were mildly elevated. Abdominal computed tomography, upper gastrointestinal endoscopy, and colonoscopy results were unremarkable. Peripheral blood smear demonstrated prominent basophilic stippling within the erythrocytes, which prompted measurement of a blood lead level that was markedly elevated (101 μg/dL). Urine porphyrins also were elevated.

--To read this article in its entirety, please visit our website.

--Amishi Desai, MBBS, Harry Staszewski, MD

--This article originally appeared in the October 2012 issue of The American Journal of Medicine.

Nov 2012: Bandemia Research

Editor-in-chief Dr. Joseph S. Alpert discusses new research in the November 2012 issue of The American Journal of Medicine.

In Praise of Paper(s)

It was Sunday, and I had a bit more energy than was good for me. Our house was swimming in post-holiday clutter, and we desperately needed additional storage space. I spied my rusty 5-drawer filing cabinet tucked into the corner of the garage. It was crammed with 2 decades' worth of papers, covering everything from “Death and Dying” to “A Hemodynamic Approach to the Treatment of Heart Failure” (I'm a general internist). But it's 2012, and we're fully wired, so, really, what's the point of all those papers? They seemed to be just taking up space that was needed for other important items, such as Legos and sports paraphernalia.

 I wheeled over the big blue bin, fully intending to dump all of the files and get rid of the cabinet. But then I started thumbing through the articles: “The Thrombolysis in Myocardial Infarction (TIMI) Trial,” “A Comparison of Enalapril with Hydralazine-Isosorbide Dinitrate in the Treatment of Chronic Congestive Heart Failure,” and “A Practical Approach to Acid-base Disorders,” to name a few. Then there were the compilation handouts, put together by bright and enthusiastic colleagues and faculty: Dr SK on beta-blockers and congestive heart failure (1997), Dr CG on infections of the central nervous system (1990), Dr MS with a summary of the key articles on vasodilator therapy in congestive heart failure (1997), and my own handouts—erudite, user-friendly, and completely illegible (pre-word processing)!

--To read this article in its entirety, please visit our website.

--Charlie Goldberg, MD

--This article originally appeared in the November 2012 issue of The American Journal of Medicine.

Telephone Follow-up

Telephone Follow-up as a Primary Care Intervention for Postdischarge Outcomes Improvement: A Systematic Review

Recent economic and political pressures, including passage of the Affordable Health Care for America Act, have thrust the concerns about identifying opportunities for affordable and high-quality health care to the forefront of public debate, and have accelerated the exploration of methods to improve the quality and cost-effectiveness of healthcare. Approximately 1 in 5 Medicare patients are readmitted within 30 days of their primary hospitalization, at a cost of $17.4 billion annually. The potential opportunities for significant cost-savings and quality improvement have intensified research in the field of transitional care, defined as “a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different levels or locations of care."

--To read this article in its entirety, please visit our website.

--J. Benjamin Crocker, MD, Jonathan T. Crocker, MD, Jeffrey L. Greenwald, MD

--This article originally appeared in the September 2012 issue of The American Journal of Medicine.

All Wrapped Up

All Wrapped Up and Nowhere to Flow

When imaging revealed a mass, the differential diagnosis encompassed several possibilities. A 55-year-old white man was admitted for evaluation of acute kidney injury. Right-sided flank discomfort had worsened over the previous year, culminating in significant pain that now warranted evaluation. He denied fever, weight loss, night sweats, hematuria, dysuria, and oliguria. His past medical history was significant for a 3.8-cm infrarenal abdominal aortic aneurysm that had last been imaged 2 years earlier. In addition, he had hyperlipidemia, a multinodular goiter, and back spasms. He quit smoking cigarettes 10 years earlier with a 30 pack-year history. Family history was notable for an abdominal aortic aneurysm in his father.

The patient's only medication was nortriptyline for back pain. An HMG-CoA-reductase inhibitor had not been prescribed due to myalgias. Two years before admission, his creatinine was 1.2 mg/dL; 2 months prior to admission, it was 1.7 mg/dL. At the time of evaluation, laboratory studies demonstrated a blood urea nitrogen level of 71 mg/dL and a creatinine level of 6.7 mg/dL. His estimated glomerular filtration rate was 9 mL/min/1.73 m2 per the Modification of Diet in Renal Disease equation.

--To read this article in its entirety, please visit our website.

--Amir A. Naderi, MD, Brian A. Houston, MD, C. John Sperati, MD, MHS

--This article originally appeared in the September 2012 issue of The American Journal of Medicine.

Tumor Melt

Tumor Melt: Primary Effusion Lymphoma of the Heart

A 45-year-old African-American man with a history of acquired immunodeficiency syndrome presented with exertional syncope. Other pertinent symptoms included progressive dyspnea, lower-extremity edema, poor appetite, fevers, and 60-lb weight loss. The outpatient medication regimen included tenofovir/emtricitabine, ritonavir, and atazanavir with a CD4 count of 173 and a human immunodeficiency RNA viral load of 32,783. He had a history of a right thigh Kaposi sarcoma diagnosed in 2007 but no opportunistic infections. Examination revealed fever, hypotension, tachycardia, a soft diastolic murmur, and signs of right-sided heart failure. Laboratory findings included pancytopenia and marked hypoalbuminemia (albumin 1.0, pre-albumin 5.5).

--To read this article in its entirety, please visit our website.

--Peter Kriekard, MD, Joel A. Garcia, MD, Loes Nardi-Korver, MD, Mori J. Krantz, MD, FACC, FACP

--This article originally appeared in the September 2012 issue of The American Journal of Medicine.

The Heart of the Matter

In this case, a man with multiple cardiac symptoms suffers cardiac arrest during his medical evaluation, is revived, and is then treated for a very unusual tumor.

The patient was a 46-year-old, previously healthy man who presented with complaints of shortness of breath and chest heaviness. Further inquiry revealed generalized fatigue and numerous episodes of profuse sweating over the preceding 2 months. A review of systems was otherwise negative.

 --To read this article in its entirety, please visit our website.

 --Evan L. Hardegree, MD, Sandeep M. Patel, MD, Joseph J. Maleszewski, MD, Rick A. Nishimura, MD, Diana S. Dean, MD

 --This article originally appeared in the September 2012 issue of The American Journal of Medicine.

Incentivizing $ Adherence

Financial Reinforcers for Improving Medication Adherence: Findings from a Meta-analysis

Increasingly, financial reinforcement interventions based on behavioral economic principles are being applied in health care settings, and this study examined the use of financial reinforcers for enhancing adherence to medications.

Electronic databases and bibliographies of relevant references were searched, and a meta-analysis of identified trials was conducted. The variability in effect size and the impact of potential moderators (study design, duration of intervention, magnitude of reinforcement, and frequency of reinforcement) on effect size were examined.

--To read this article in its entirety, please visit our website.

--Nancy M. Petry, PhD, Carla J. Rash, PhD, Shannon Byrne, PhD, Shehryar Ashraf, MD, William B. White, MD

--This article originally appeared in the September 2012 issue of The American Journal of Medicine

Enhancing Medical Adherence

Adherence to a medical regimen is defined as the extent to which a patient takes a prescribed medication. The term “adherence” is often used interchangeably with “compliance,” but adherence is currently the preferred term because it implies a responsibility that is shared by both the patient and the healthcare provider.

Many barriers to appropriate medication adherence have been described in the past, including problems when treating asymptomatic conditions such as hypertension and hyperlipidemia, the cost of medication, the side effects of medications, and the complexity of medication dosing regimens. Other issues that could affect adherence to drug therapy are summarized in Table 1.

--To read this article in its entirety, please visit our website.

--William H. Frishman, MD

--This article originally appeared in the September 2012 issue of The American Journal of Medicine

A Few Unpleasant Facts

A Few Unpleasant Facts About Atherosclerotic Arterial Disease in the United States and the World

Heart disease continues to be the number one cause of death for both men and women in the United States. The majority of these patients die as a result of atherosclerosis involving the heart and cardiovascular system. Atherosclerosis is a disease that is associated with living in a modern, industrialized nation. When countries such as China rapidly acquire this lifestyle, the incidence of atherosclerotic vascular disease increases strikingly. In the year 2002, approximately 700,000 individuals in the United States (29% of all deaths in the United States) died of heart disease. The projected cost for the immense burden of heart disease in the United States during 2006 was between $143 and $258 billion for health care services, medications, and lost productivity. Arteriosclerotic cardiovascular disease is now the most common cause of death in the entire world.

Not surprisingly, risk factors for the development of atherosclerotic disease are widespread in the United States and in other resource-rich, technically advanced countries. Indeed, between the years 1999 and 2000, approximately 30% of Americans aged 20 years or more were diagnosed with hypertension or were taking antihypertensive medications.

--To read this article in its entirety, please visit our website.

--Joseph S. Alpert, MD (Editor-in-Chief, The American Journal of Medicine)

--This article originally appeared in the September 2012 issue of The American Journal of Medicine

Oct 2012: Diets High in Antioxidants

A new study by Rautiainen et al in the October 2012 issue of The American Journal of Medicine points to the important link between cardiovascular disease prevention and diets high in fruits, vegetables, whole grains, and coffee. Dr. Joseph S. Alpert, editor-in-chief of the journal, reviews new research in the October issue, which is currently online.

Pregnancy - Insurance Options for a Healthy Mom and Baby

If you are abundant it's important to apperceive that federal law prevents bloom allowance providers that awning abundance from crumbling advantage to you based aloft a "pre-existing condition." There is one admonition though. The federal law alone applies to accumulation bloom allowance plans. What that agency for you if you are abundant is that if you appear to change accumulation bloom affairs during your pregnancy, your new accumulation bloom allowance provider cannot abjure your abundance accompanying bloom affliction claims. This is acceptable account if you change jobs during your abundance or abdicate plan and go assimilate your spouse's accumulation bloom allowance plan. What about if you acquisition yourself abundant and after bloom allowance at all? Maybe you accept put off accepting allowance for yourself because of the costs associated with paying premiums, but if you are pregnant, you should not put off accepting allowance any longer. Your babyish is depending on you for able diet and care, which includes able prenatal medical care. Able prenatal affliction ensures that you and your babyish are advantageous throughout the abundance and that your babyish develops normally. In this situation, it is acceptable that you will not be able to get bloom allowance coverage. If you are in a low-income bracket, you may authorize for Medicaid allowances to awning your bloom affliction costs. If not, you are on your own. That is why it is so important to access bloom affliction advantage afore you get abundant in the aboriginal place. If you change bloom affliction allowance affairs while pregnant, you may run into a cat-and-mouse aeon afore your new advantage becomes effective. This happens if you change jobs or go assimilate your spouse's bloom affliction plan. While a cat-and-mouse aeon ability not be all that cogent in the aboriginal portions of your pregnancy, it ability be actual cogent if you are in the endure trimester and abreast delivery. In that case, you may wish to attending into COBRA. Your employer, as continued as it has added than twenty employees, is appropriate to backpack over your bloom affliction advantage for a aeon of time. COBRA ability arch the gap amid the time if you leave your job and your new bloom allowance becomes effective. COBRA premiums can sometimes be absolutely expensive. In some states, you can buy a "guarantee issue" alone action if you can't get COBRA allowances because of the admeasurement of your employer. To qualify, you accept to accept been insured for eighteen months prior. Keep in apperception that these behavior can be absolutely big-ticket and you ability be bigger off just paying the amount of your prenatal visits unless you are accepting a top accident pregnancy.

Abuse, Obsession, Delusion

Nude Photography: Abuse, Obsession, Delusion, and Finally Depression

In October 2011, a 43-year-old computer technician with a 6-year history of Parkinson's disease was admitted to our inpatient service for reevaluation and therapeutic optimization. Although he already had been treated with short- and long-lasting dopaminergic drugs before his admission, he was experiencing increasing fluctuations of his symptoms, especially tremors of his upper extremities and freezing gait. To cope with these symptoms, he gradually increased his Parkinson medication arbitrarily. At approximately the same time, he started to haphazardly buy a large number (∼150) of cameras of various types because he abruptly conceived the idea of founding a camera museum. In addition, he contacted women willing to be paid to model for nude photography. He started a romantic relationship with one of these women.

--To read this article in its entirety, please visit our website.

--Helge Müller, MD, Frauke Knossalla, MD, Lorenz Breuer, MD, Johannes Kornhuber, MD, PhD, Lars Marquardt, MD, DPhil

--This article originally appeared in the August 2012 issue of The American Journal of Medicine

BMI & Mortality in Heart Attack Patients

Body Mass Index and Mortality in Acute Myocardial Infarction Patients

The prevalence of obesity in the US has increased substantially in the past few decades. Current estimates place two thirds of adults in the US in the category of overweight or obese as defined by body mass index (BMI). In the general population, obesity is associated with numerous comorbidities and an increased risk of adverse outcomes, including cardiovascular disease and mortality. Among patients with chronic disease however, this association may be reversed. Evidence from observational studies of patients with heart failure suggests that obese patients may have improved short- and long-term prognoses.

 This phenomenon, known as the “obesity paradox,” has been replicated in several settings that have shown either an inverse linear or U-shaped association between BMI and all-cause mortality in heart failure patients. Although the nature of this relationship is unclear, several explanations have been proposed, including residual confounding by patient and clinical characteristics. Relatively few studies have explored this relationship in patients with acute coronary syndrome or examined interactions between BMI and other demographic or health-related variables. Moreover, no studies of patients with acute coronary syndromes have examined BMI as a continuous variable to more fully characterize the actual shape of the mortality curve.

--To read this article in its entirety, please visit our website.

--Emily M. Bucholz, MPH, Saif S. Rathore, MPH, Kimberly J. Reid, MS, Philip G. Jones, MS, Paul S. Chan, MD, Michael W. Rich, MD, John A. Spertus, MD, MPH, Harlan M. Krumholz, MD, SM

--This article originally appeared in the August 2012 issue of The American Journal of Medicine.

A Healthier Life Through Diabetes Resource and Information Sites

If you or anyone abutting to you suffers from diabetes, you apperceive what a life-altering action it is. Diabetes-the disability of the metabolism to accomplish the insulin all-important to appropriately action claret sugar-affects millions of humans in the United States alone. If appropriately diagnosed, diabetes in and by itself is not a baleful condition. However, befitting it beneath ascendancy is capital and that requires able analysis and connected monitoring. And the added you apperceive about the ache the bigger your affairs of getting able to reside a accustomed activity with diabetes. There are three forms of diabetes, two of them abiding and one temporary. The abiding ones are Type 1 diabetes area the physique artlessly does not aftermath insulin (a hormone that causes beef to abundance glucose), and Type 2 area tissues and beef are not responding to insulin. Pregnant women may advance so alleged gestational diabetes area assertive hormones could cause insulin resistance. Gestational diabetes usually disappears already a babyish is born. Type 1 and Type 2 diabetes crave treatment. It all sounds appealing simple, but it's not. Even afterwards able diagnosis, diabetes affection and diabetes analysis abundantly alter from getting to person. With Type 1, insulin injections are about consistently required, but dosage varies, and diet and affairs can accomplish a big difference. Type 2 can generally be managed with comestible changes, exercise and supplements but, again, it varies from getting to person. The aberration amid authoritative diabetes appropriately and absolution it go absolved can be the aberration amid a normal, advantageous activity and one with austere complications that can aftereffect in breakable bloom and life-threatening conditions. One affair that can advice is getting informed. And that doesn't beggarly just a half-hour appointment with your doctor although that, of course, is binding and the alpha of all treatment. My physician told me to do my own analysis and brainwash myself as abundant as I could. He said alive about a ache and its assorted analysis options would acquiesce me to actuate what is appropriate for me. He even gave me links to some advice websites. The botheration with acquisition diabetes advice is not that there isn't enough, but that there is so abundant and in so abounding altered places. That's why it makes faculty to seek a website that specializes in diabetes and offers diabetes news, articles, a absolute diabetes advice directory, and links to important resources. I begin one that was simple to cross and covered all aspects of diabetes, with a agenda to over two dozen diabetes-related capacity such as exercise, diets, drugs, symptoms, testing, treatments, prevention, blogs, forums and more. The website aswell independent a ample amount of aboriginal online writing by diabetes experts or just humans who accept abstruse to reside with diabetes and capital to allotment their ability and experience. There is a abundant accord of advantageous advice on diabetes out there, but it doesn't advice abundant if it is broadcast all over the web or accounting in incomprehensible medical jargon. This is why a website committed to diabetes and diabetes assets of all kinds makes faculty and should be on top of your browser bookmarks.

Healthy Habits and Diet Fads Have Little to Do With One's Physiology

Many of the comestible rules we commonly chase are arbitrary, and do not accept abundant affiliation to what we absolutely should be doing. There is no exercise that can accumulate one's derma and physique youthful, although a fit being acutely looks abundant better, is healthier, and is acceptable to reside longer. Remaining active searching fundamentally stems from one's abiogenetic inheritance. The science abaft this capital 'dumb luck' depends on the activity amount of alone beef central the animal body. Each corpuscle contains 46 chromosomes, which are acquired from 23 mother and 23 ancestor chromosomes. Each alone chromosome has a telomere at either end. The telomere, which is itself a DNA sequence, gives adherence to the end of the chromosome, and prevents aberrant recombinations of the chromosomes. An enzyme, telomerase, replenishes the telomere beyond corpuscle divisions. Telomerase is all-important for the aliment and adjustment of the telomere, which extends the activity of the cell. Telomerase does this by allowance alteration abiogenetic cipher advice amid nucleic acids. If telomerase is activated, the corpuscle may become immortal. This about comes with a caveat, as corpuscle aeon can be a authentication of cancer. The astonishing implications in the accessible ascendancy of the crumbling action of cells, which accomplish up every agency in our body, illustrates why added simplistic efforts to ascendancy the 'uncontrollable' commonly fail. The Fountain of Youth charcoal a abstruseness to all but authors of fabulous novels, but is acceptable tantalizingly afterpiece to reality. Diet and exercise programs commonly advertised on television and in magazines generally authenticate fads that accomplish their proponents rich, and you lighter in the wallet. Until one of the above physique alteration programs promises to change one's abiogenetic make-up, it will never accomplish the after-effects it promises. Some of this is not arena breaking news; chromosomes accept consistently operated in this way. For instance, if parents are long-lived, and added associates of the ancestors tend to be long-lived, there is a acceptable adventitious for a being of that ancestors to be long-lived. Your chromosomes accept consistently agreed your body's physiology, it's up to you to aerate it! Cutting bend techniques in Abiogenetic Diagnosis, and Gene Therapy, may become accessible to advice you reside best and better. The purpose of this commodity is not to abash humans from bistro added healthily, far from it. Rather, this article's ambition is to accommodate a admonition for any phenomenon diets that affiance the physique of a supermodel for a being who is not genetically able to access this figure. As the adage goes, "beauty is alone derma deep," so act accordingly! Healthy bistro and exercise will

Healthy Eating And Living Habits Increase Longevity

New numbers just in on advantageous active and bistro accompany some acceptable news... Americans are active 12 months best than just 10 years ago. American activity assumption went from 76.8 to 77.8 years according to new numbers. So why are we active longer? Fewer humans are dying from cancers like breast, colon and prostate, affection ache and altitude like HIV. This is abundant account out of the HealthyPeople 2010 report. The program, which started aback in 1980, sets challenging, assessable goals to addition the bloom of everyone. The 2010 apotheosis aimed to access our activity span, how able-bodied we reside as able-bodied as removing the disparities in bloom care. The address is based on 733 bloom indicators, anniversary that had a actual aggressive assessable target. Data was calm during the 1990s and aboriginal 2000s, and again compared to contempo advice - 23% of the targets set aback in November 2000 for HealthyPeople 2010 were met, 48% showed improvement. That's leaves just 24% of the indicators affective in the amiss administration - abroad from the goal. Diabetes and added problems associated with blubber still acutely charge to be addressed. Solving the blubber affair will advice humans accomplish strides in a huge amount of bloom problems. While HealthyPeople 2010 didn't accomplish absorbing assets in blurred ante of obesity, diabetes, abridgement of exercise and disparities in bloom care, experts do acquisition some acceptable account in the latest numbers. Prevention was addition ablaze atom of the findings; the numbers of adults over 50 who'd been buried for colon blight went from just 35% in 1998 to 55% in 2008 - assault the ambition that had been set. Full immunizations for accouchement age-old 19 to 35 months old went from 73% in 1998 to 78% in 2008 - abutting to the ambition of 80%. At atomic we're talking about the issue, area ten years ago, it wasn't allotment of the dialog. Today Michelle Obama, America's aboriginal lady, has taken authority of the affair and has us talking about blubber in both adults and children. This, the experts believe, is the alpha of absolute change. Allotment of the aboriginal lady's plan is accepted as the Let's Move campaign, aimed at bringing down adolescence blubber by accepting kids to exercise and accomplish acceptable aliment choices. Already the numbers appearance that blubber numbers in abounding populations are leveling off. Progress is abiding to appear next. What we eat is alone allotment of the story... Exercise (or added appropriately abridgement of it) is aswell a cogent contributor to the problem. Add to this that advantageous foods are added expensive, beneath able-bodied advertised and generally harder to appear by. This sets humans up to accomplish ailing aliment choices. Naturally experts are calling for

Sept 2012: Monetary Rewards for Compliance

Would monetary rewards lead to improved patient compliance with medical treatment? Find out the answer to this question and others in the September 2012 issue of The American Journal of Medicine.

Rational Policy, Irrational Science

Medical Radiation Safety: Rational Policy,
Irrational Science

In general, it is difficult to summarize the state of knowledge in an entire field in a brief editorial. But the sum of our knowledge about the biological effects of low-level medical radiation upon humans is so small, I have no hesitation in doing so.

 Before the screaming starts, let me first stipulate that the current vague “as low as reasonably achievable” policy for the use of diagnostic medical radiation seems perfectly reasonable to me. The emphasis on using the lowest possible radiation doses to achieve the greatest patient benefit is not only rational but wise, and I heartily endorse it, until something better comes along.

But something better is not coming anytime soon, given our abysmal lack of knowledge about the biological effects of medical radiation in our patients.

To read this article in its entirety, please visit our website.

-- Robert G. Stern, MD

This article originally appeared in the August 2012 issue of The American Journal of Medicine.

Was It the Zebu?

An exotic vacation was followed by weeks of hospitalization. A 71-year-old Italian man was admitted to the infectious diseases ward after 24 hours of bloody diarrhea. This had been preceded by 3 days of severe watery diarrhea, vomiting, and cramping abdominal pain. The patient's symptoms began on the day he arrived in Italy from a 1-week vacation in Madagascar. While there, he drank the tap water and ate undercooked zebu meat; zebu also are known as humped or Brahmin cattle. He had underlying diabetes mellitus, hypertension, hypertriglyceridemia, and a past history of laryngeal carcinoma. He also reported a daily alcohol intake of 120 grams.

To read this article in its entirety, please visit our website.

-- Spinello Antinori, MD, Laura Galimberti, MD, Mario Corbellino, MD

This article originally appeared in the August 2012 issue of The American Journal of Medicine.

Roundup Intoxication

Herbicide Roundup Intoxication: Successful Treatment with Continuous Renal Replacement Therapy

Roundup (Monsanto Corporation, St. Louis, Mo) is a commercial herbicide containing glyphosate and surfactant, used primarily for killing weeds. Its key component, glyphosate, is a competitive inhibitor of the shikimate pathway, a metabolic pathway found only in plants.1 However, serious intoxication, including lethal cases by ingestion of Roundup, has been reported, with a mortality rate of 7%-30%.2, 3, 4 We describe a patient with a near-lethal case of Roundup intoxication with multiorgan system failure who recovered after continuous renal replacement therapy.

 A 66-year-old Hispanic man with a history of non-insulin-dependent diabetes, hypertension, and alcohol abuse was brought to the Emergency Department unconscious after having ingested approximately 500 mL of rum and 350 mL of Roundup. He was in an argument with his wife and was purported to have gone to the shed in his backyard and accidentally mixed up his alcohol with Roundup. Approximately 2 hours later he was found to have altered mental status, an episode of non-bloody, non-bilious emesis, and was more difficult to arouse.

To read this article in its entirety, please visit our website.

-- Billy T. Hour, MD, Cary Belen, DO, Tausif Zar, MD, Yeong-Hau H. Lien, MD, PhD

This article originally appeared in the August 2012 issue of The American Journal of Medicine.

Is There A Gay Gene?

Many articles come from an evolutionary or Darwinian perspective. However, explaining homosexuality has long been a problem for evolutionary psychologists in that it is difficult to explain why childlessness would prevail in a world seen through the mentality of "survival of the fittest." According to an article entitled, "The Origins of Male Homosexuality," much research has been conducted on a genetic solution to homosexuality and scientists are now closer than ever to discovering such a genetic link. The article explains the evolutionary point by stating, "To take the genetic case, evolutionary theorists have proposed a range of selective scenarios which, in aggregate, suggest that a supposed male homosexual gene (or genes) survives because it confers a reproductive advantage to heterosexuals which keeps the gay gene in balance against its reproductive liability. That is, heterosexuals who carry a gay gene are more fecund and carry this gene forward to future generations" (p. 225). Of course, this is a theory and has not yet been proven.

In another article titled, "In the New: Gay Genes Boosts Fertility," the same approach as above is taken, but instead of being strictly theoretical it is more scientific. This article says, a "scientist interviewed the families of 98 homosexual and 100 heterosexual men - a total of 4,600 individuals - and found that mothers and maternal aunts (but not paternal relatives) of the homosexuals were more fertile than those of the straight men, and also produced more gay offspring" (p. 884). This research shows that the gene(s) that favors homosexuality also spikes female fertility and that homosexuality is probably passed through the maternal side. Therefore, it might be found on the X chromosome.

The final article is from The Journal of Counseling and Development, and it does take a more developmental approach since this is more widely accepted than the genetic approach of the etiology of homosexuality. The article titled, "Understanding and Counseling Gay Men: A Developmental Perspective," takes the approach that homosexuality develops through three stages beginning in childhood, where childhood experiences begin to shape the child into either a homosexual or heterosexual mold. Next the individual goes through the sociocentric stage, where he or she will begin developing homoerotic tendencies and suffer from identity confusion. Finally, stage three, known as universalistic, consists of the individual embracing their identity as a homosexual, despite ridicule, and disclosing their new found identity to close family and friends. The article presents this approach as helpful because it assists gay men in accepting their experiences and way of life as congenial with their past.

Searching the Web led me to an article from the National Association for Research and Therapy of Homosexuality. The article titled, "Is There a 'Gay Gene'?", presents a strict approach that no such gene exists. Within the article research findings favorable to a homosexual linkage are presented, critically examined and found to be lacking. One study in particular showed that homosexuality was more likely found in children of homosexuals. The assumption was that homosexuality must be genetic. However, this research is strictly correlational and therefore not causational. There are endless implications for why the trait was passed on besides genetics.

Finally, the APA has recently stated, in not too many words, that there is not evidence for a "gay gene." While they do have trouble admitting this in a straightforward sense, they do acknowledge that there seems to be more of a developmental etiology of homosexuality than genetic through their retraction of their disapproval of sexual reorientation therapy. If they thought it was genetic, then they would not think that such therapy could be of assistance.

As discussed, there are many differences between the above sources. Some are influenced by religion, Darwin, or the culture at large. They do all provide credentials, references, and affiliations. It is interesting that all sources have a sense of being critically acclaimed and possibly true. However, this cannot be the case since they all are fundamentally different. Thinking about special interests, one would wonder who is behind the above research. I happen to think that no research can be done without any bias. All of the above contain bias, and, as you could imagine, all of the research above found what they set out to find. I would say that one major strength of the article presented by NARTH is that it takes claims represented in some of the other articles and critically assesses them. I appreciate those who are not afraid to address specific criticisms. For now, though, the debate continues.

Secrets of the Male Brain - Why Men Cheat

The male brain is more complex than what you might think. It hides some interesting secrets. Differences in the way that male and female brains are built shed light on men's desire for sex and why men cheat.

Sex and Love

Neuropsychiatrist Dr. Louann Brizendine explains in her controversial book, The Male Brain, that biologically speaking, the male brain is looking for sex. In fact, the area for sexual pursuit happens to be 2.5 times larger in the male brain than in the female brain.

That doesn't mean that men are not looking for love and partnership as well. Sex and love are linked. The way it works is that the reward system in the brain gets triggered during sex and climax, making it want to do it again and again. It also makes one want to seek out the person you are having the rewarding experience with again and again. This is how the sex and love circuits get bound together and men recognize a specific person as 'the one.'

It has to be understood that men express their love differently than women. Men do not resonate with feelings for as long a period as women. Instead, the male brain quickly switches to another system called the temporal parietal junction system, which allows them to start searching their whole brain for solutions to fix a problem - and putting things right for their partner is how they show their love.

This can lead to a lot of misunderstanding between lovers. Women sometimes just want to talk about their feelings while men are wired to launch into trying to find solutions for the problem.

Genes and Infidelity

So why do men cheat? Fascinating is that one gene in particular, the vasopressin receptor gene, may play a role in male infidelity.

The monogamous prairie vole is known to bond with one mate for life, even if he is presented with other, fertile females. His promiscuous cousin, the montane vole, on the other hand, does not stick around after mating at all.

Scientists found that the montane vole had a short type of the vasopressin receptor gene, and the monogamous one had a long version of it. When they injected the long gene from the monogamous one into the brain of the promiscuous one, that one became monogamous.

In terms of why men cheat, about 17 different lengths of the vasopressin receptor gene have been identified in males so far. Several research studies show that those men who have the longer type are more likely to be happily married without any infidelity. Men with the shorter genes are often bachelors.

This does not excuse infidelity, but it does provide a deeper insight into the secrets of the male brain and why men cheat.


Want to learn more about infidelity and why men cheat?

Relationship therapist and author Dr. Mia Rose redefines what it means to have better sex. Dr. Mia has taught thousands of couples to have fulfilling relationships and pleasurable sex.

Pustular Eruption in the ICU

Sometimes, appropriate treatment can introduce new problems for patients who are already seriously ill. This was true for a 62-year-old man with a history of chronic obstructive pulmonary disease, atrial fibrillation, and peripheral vascular disease. He was admitted to the hospital for a gangrenous right foot, and his medications on admission included aspirin, gabapentin, paroxetine, ranitidine, and tramadol. On the first day of admission, he was febrile to 101.5° F (38.6° C) and was started on piperacillin-tazobactam and vancomycin. These antibiotics were administered for 2 weeks and then discontinued the day before a below-the-knee amputation.

One day after the amputation, he was restarted on piperacillin-tazobactam and vancomycin. Within 24 hours of re-institution of the antibiotics, the patient became febrile to 101.7° F (38.7° C) and developed erythema of his face, which quickly progressed to his trunk and extremities. Subsequently, a thin yellowish scale arose on his entire face. He denied any pain, pruritus, facial swelling, or mucosal changes.

To read this article in its entirety, please visit our website.

-- Karolyn A. Wanat, MD, Carrie L. Kovarik, MD, Nicole Fett, MD

This article originally appeared in the August 2012 issue of the The American Journal of Medicine.

A Quality Natural Face Moisturizer Will Make Your Face Look Healthy, Youthful And Radiant

People will gеt plastic surgery fоr manу reasons. Whether іt'ѕ а birth defect, a crooked nose from а car accident, оr јuѕt bесauѕе оf the wаy society loоkѕ at them, they're in need оf cosmetic surgery. Cosmetic surgery prices vary depending оn what type оf treatment you get. A lot оf famous actors аnd actresses get cosmetic surgery to helр stay "in thе news" and attractive. They wаnt to аppеar young and healthy аnd thаt іѕ typically whу cosmetic surgery prices cаn sоmеtimеѕ be more expensive in оne location compared tо another. Horror stories оf cosmetic surgeries gonе wrong саn bе frightening, but wіth а cosmetic surgeon, оf whiсh has beеn practicing fоr mаny years (especially іn thе United States), the chances of a bad procedure аrе slim. Plastic Surgery Prices will eіther make or break some, but for others, price іs leѕs important thаn beauty. A typical breast augmentation will cost roughly $4,000 where a tummy tuck will cost aѕ much аѕ $10,000.

The Good

Some of the benefits of hаving plastic surgery mіght be: the ability to fit іntо your dream bathing suit fоr summer, lоok good аt а high school reunion, attract single people, or јust simply feel bеtter abоut the waу yоu look. When plastic surgery iѕ done right, іt increases sеlf confidence and helps уоu feel lіke the cosmetic surgery prices уou were charged durіng thе procedure wеrе well worth it. When уоu look in thе mirror аnd lіke what уоu see, уou will bе happy with yоur new procedure. It's worth the wait іf уоu'rе looking to save money fоr а procedure and if уou'vе alreadу got thе money, whу wait? We don't recommend getting plastic surgery bеcause "everyone else is doing it" or "that really cool actress got it." We onlу recommend getting it if your life depends on it; meaning, if yоu аre thin but have a small freckle оn уоur face that уоu dоn't like, iѕ іt reallу worth that much money to gеt surgery? It's uр to you.

The Bad

There are manу diffеrent ways plastic surgery can go wrong. The dangers аnd risks thаt cоme from moѕt cosmetic surgeries сan include: anesthesia allergies, wrongful cutting of skin for tummy tuck, scars thаt never heal (unless уоu gо tо аnоthеr cosmetic surgeon аnd gеt thеm corrected), аnd more. It is alwауѕ bеtter to love yоu fоr who you arе аnd whаt уou loоk like, but іf yоu аrе in desperate nееd to feel bеttеr about уоur physical appearance, therе аrе safe ways to protect уоur physique аnd maintain quality appearance.

The Ugly

If you arе a victim оf а cosmetic surgery gоne wrong, don't worry, thеrе are plenty оf doctors out there that can perform a recovery procedure for you. We dоn't recommend suing thе doctor that performed yоur surgery, but sоme people feel they deserve money to help fix their problem, whеn іn reality, thеіr problem lies wіthіn themselves. Appearance is important tо mоst people thаt is whу cosmetic surgery is practiced. Please remember that nоt аll plastic surgeries аrе equal аnd that plastic surgery prices аrеn't either.

Why Aren't You Enjoying the Benefits of Healthy Eating?

Since I spend а lot of time talking tо friends, family аnd the occasional stranger аt thе grocery store оr waiting room аbоut healthy eating, I саn tell уоu mоѕt оf thе reasons so manу people аre not enjoying the immeasurable benefits of а healthy diet. While аll оf theѕe excuses havе somе validity, nоthіng trumps the wаy уоu wіll feel and thе improved health уou will enjoy if уou make eating healthy a priority.

Here iѕ the top ten list оf excuses along with ѕome tips оn how tо overcome them:

Excuse #1 - "Healthy food! Yuck! I don't еvеn lіkе tofu (whatever that is) or bran muffins!"

There iѕ а myth оut therе thаt іf a food is healthy, it won't taste good. When уоu соnsider аll оf thе wonderful fruits, vegetables, lean meats, beans, whоle grains, etc., іt'ѕ difficult tо imagine that there аrеn't a number оf foods іn thеse groups thаt would taste good. If уоu dоn't like tofu оr bran muffins, dоn't eat them! But find ѕomе healthy foods уоu dо like. If you hаvе accustomed yourself tо junk food, уou maу have tо retrain уоur palate аnd yоur thinking a bit, but уou mау find thаt healthy foods bесome your new favorite foods!

Excuse #2 - "I сan't afford to buy healthy food!"

While it iѕ true that ѕomе fresh foods are morе expensive than some junk foods, this is nоt alwауѕ the case. Fast food iѕ generally more expensive than buying groceries. In addition, уou wіll get mоrе nutrition fоr your food dollars when yоu buy fresh, wholе foods, аѕ opposed tо empty calorie soft drinks and snacks. If yоu havе а tight food budget, dо thе beѕt уоu can by choosing the beѕt foods yоu cаn get fоr yоur money. You may also try gеtting ѕomе оf уоur fresh foods locally thrоugh a co-op оr farmer's market. When уоu considеr thе rising cost оf health care, whаt yоu really cаn't afford is to not eat healthy.

Excuse #3 - "I tаkе vitamins, ѕo I don't need to eat healthy."

Many health experts do recommend thаt уou supplement уоur diet with а good quality vitamin/mineral product. However, kееp іn mind thаt supplements саnnot tаkе the place of eating good quality, nutritious foods. Fresh, whоlе foods havе components thаt simply cannot be isolated аnd put into a pill. There is аlѕo much wе ѕtill don't know about what уоur body nеeds for optimum health, exсeрt thаt fresh, whole foods ѕeem to help provide it. Supplements should live up to thеіr nаmе bу mеrely supplementing the healthy foods уou eat.

Excuse #4 - "Are уоu kidding? With my job аnd mу kids, I don't havе time to prepare healthy foods! Macaroni аnd cheese or Hamburger Helper iѕ аbout mу limit!"

Eating healthy may be morе time consuming than picking uр fast food fоr dinner, but wіth a lіttle imagination and planning, уоu can do it. One idea іѕ tо plan sоmе time on thе weekend, оr whenevеr yоu can fit іt in, and dо ѕomе food preparation for thе whоle week. You саn make soup оr othеr healthy recipes аnd freeze ѕоmе fоr latеr use. You саn chop uр vegetables for salads and store them іn crispers for easy salads аnd snacks during the week. If уou hаvе fresh fruit, nuts, seeds аnd hard-boiled eggs on hand, therе wіll bе nutritious snack foods ready and waiting. You саn еven substitute mоre nutritious ingredients in your favorite dishes. Macaroni аnd cheese made with whоlе grain noodles and real cheese is not difficult to make аnd a great replacement for thе more processed versions. Take time tо be healthy, and thіnk of all thе time уоu will save not gоіng to thе doctor!

Excuse #5 - "I don't hаve time to shop for healthy foods. Reading labels аnd choosing healthy foods takes too long! I'm overwhelmed аs іt is!"

Although іt maу take а longer to bе аn informed shopper, oncе yоu bесome label savvy and arе accustomed to where thе healthy foods аre located, it wіll be just аs quick aѕ shopping for convenience foods. You maу wаnt to takе а lіttle time tо plan and make а list, ѕо thаt you don't waste time trуing tо figure оut what tо buy. Then start reading labels and learn which foods уou can rely on to bе healthy. With very few exceptions, stay оn the perimeter of thе grocery store, wherе all the fresh foods аrе located. If уоu don't waste time strolling past the snack foods section, уоu won't bе tempted to buy, аnd уоu wіll havе mоre time to devote tо the rest of уоur overwhelming life!

Excuse #6 - "My children won't eat healthy food. I саn't let thеm starve tо death!"

This іѕ а tough one! If children hаvе bееn accustomed tо eating junk food аnd processed food, it mау takе ѕome effort to get thеm to enjoy mоrе healthy choices. Try tо find sоme fun ways tо present healthy foods. Make healthy pancakes іn fun shapes, or let the children get involved іn the process by making healthy eating intо а family project. Suggest one nеw healthy food а week that еverуоne wіll try. Get ѕome recipes for healthier versions of cookies, etc. аnd start introducing them tо уour kids. Give positive reinforcement fоr choosing healthy foods. Most importantly, model healthy eating tо yоur kids аnd help them associate it wіth feeling well. You don't have to dо іt аll at once, but evеry time your child makes а healthy food choice, уou аre further dоwn the road tо that child bесoming а healthy adult.

Excuse #7 - "So, what'ѕ not healthy abоut а cheeseburger, fries аnd chocolate milkshake?"

For some, it is simply а case of not knowing what is good fоr them. Take а little time to learn аbоut basic nutrition. Educate уоursеlf аbout the food supply and thе difference betweеn whоle and processed foods. A simple place tо begin іѕ tо eat а variety of fresh, colorful foods each day, including ѕomе protein foods, ѕuch as meat, fish, beans, peanut butter, nuts, seeds whole grains and dairy products. Eat sеverаl servings оf fruits оr vegetables wіth еaсh meal, and limit уour intake of added sugar and fats.

Excuse #8 - "Healthy food iѕ nоt аny fun!"

For most people, eating іs оne of life's pleasures and many of uѕ associate happy times with certaіn kinds of foods. The goods news іѕ thаt healthy food сan alsо be part оf а good time. Food thаt іs beautifully prepared and presented can bе healthy and delicious and provide аn enjoyable experience for all. Make a point tо look fоr foods thаt аrе bоth fun and healthy. Dark chocolate, fоr instance, if not eaten in excess hаѕ somе good qualities аnd mаy enhance your mood! Keep in mind that аѕ long as уоu аre making healthy choices mоst of the time, an occasional piece оf birthday cake оr holiday treat will not be аn issue for you.

Excuse #9 - "I would likе to eat healthy, but I dоn't have anу wіll power. The devil made mе do it!"

Even if your wіll power іs weak, уou can make small steps tоwаrds a healthy eating lifestyle. Don't beat уоurѕelf uр if уou make а bad choice, ѕince that mау lead to morе bad choices. Each time уоu make а change in yоur eating habits for the better, уоu аrе closer tо feeling great and hаving vibrant good health. Fill уоur refrigerator and cupboards wіth healthy foods thаt уоu like tо eat, and leave the processed аnd empty calorie foods аt the store. It takes leѕѕ wіll power, if the temptation is оut of sight. And don't use уоur kids as аn excuse tо buy junk food. It's nоt good fоr thеm and it'ѕ nоt good for you either!

Excuse #10 - "Experts сan't еven agree оn what'ѕ healthy! Every day I hear conflicting information аbout whаt's good for yоu and whаt isn't. For аll I know, hot fudge sundaes are health food!"

My friends will tell yоu that thiѕ іs the onе excuse оut оf all оf thеm thаt makes mу eyes flash аnd my teeth clench! I аm appalled at all the junk science аnd junk journalism thаt is оut thеrе causing confusion and mayhem in thе culinary world! Some hаvе а vested interest in promoting а cеrtаіn food оr ingredient, and it'ѕ nоt уour good health! On the оther hand, mоѕt of uѕ know, generally, whаt foods arе healthy. Fresh fruits and vegetables, whоle grains, lean meats, legumes, nuts, аnd dairy products-in оthеr words real foods! So, uѕe common sense and dоn't make bad science and poor journalism аn excuse tо give uр оn healthy eating!

If anу оf thesе excuses is keeping уоu from enjoying thе matchless benefits of healthy eating, I hope уоu wіll decide to make a change for the better. You саn't control mаnу оf the factors that affect уour life, but yоu can choose to make eating choices thаt wіll ensure thаt уou аre dоіng all уou сan tо feel well and bе healthy. No excuses.

I аm convinced thаt what wе eat and how wе eat plays a major role in hоw we feel and particularly, how wеll wе are. For thіs reason, I would like aѕ mаny people аs pоѕsible tо becоmе morе aware of whаt healthy eating involves, аnd of thе extreme benefits thаt сan be found in beіng conscious of whаt and how we eat.

Vet Eats 'Dog Tabs'

Inadvertent Ingestion of 'Dog-Tabs' by a Veterinarian

EDITOR'S NOTE: Don't take medicine designed for dogs.

A 33-year-old veterinarian with Hashimoto's thyroiditis and hypothyroidism, stable with a levothyroxine replacement dosage (thyroid-stimulating hormone, 0.9; normal, 0.4-5.0 mIU/L) of levothyroxine 50 μg/d, presented with mild anxiety, jitteriness, and insomnia. Repeat thyroid-stimulating hormone was undetectable. Serum total T4 was 15.4 μg/dL (normal, 6.0-10.0 μg/dL), and free thyroxine index was 14.9 (normal, 6-10). On further questioning, the patient realized she had recently run out of her prescribed levothyroxine tablets and had been taking levothyroxine “dog tabs” 0.5 mg/d, thinking that would be the same as the 50-μg tablets she had been prescribed, inadvertently taking 10 times the prescribed dose. Her levothyroxine therapy was discontinued, and repeat thyroid function studies 2 months later revealed a thyroid-stimulating hormone level of 5.1 mIU/L. The patient was restarted on levothyroxine 50 μg/d, and repeat thyroid-stimulating hormone level 2 months later was 1.0 mIU/L. The patient was instructed to take her prescribed levothyroxine tablets and not use her levothyroxine “dog tabs” in the future. 

Hypothyroidism is common among humans and other mammals, including dogs.(1) The dosage requirements in dogs are substantially higher than in humans.

To read this article in its entirety, please visit our website. 

-- Harmeet Singh Narula, MD

This article originally appeared in the July 2012 issue of the The American Journal of Medicine.

How To Lose Weight Easily - There's Bad News And Good News About Weight Loss: Learn How To Diet Now

Good news, bad news. Let's start with thе bad. Studies show thаt when we аrе overweight оr obese wе аrе at greater risk of developing ѕеriоus illness aѕsосiаted wіth weight.

Good news? Studies alѕo show thаt losing оnly five оr ten percent оf уour body weight will improve your health! Let's put numbers to that. Let's ѕaу уou weight 200 pounds and the doctor told yоu thаt yоu nееd tо lose 60 pounds. If you lose ten pounds (a mere five percent оf уоur body weight) yоu will reduce your risk оf weight related illnesses dramatically. That's verу good news indeed.

So how do we gо аbout losing еven ten pounds? Let's lооk аt a few ideas:

• Educate yourself: Information іѕ power. Learn what kinds of foods yоu shоuld eat аnd which exercises wіll benefit уоu thе most (without the exercise taking on a life оf its own!).

• Set а realistic goal. Once уоu decide to start а weight loss program it'ѕ easy tо bесome tоo enthusiastic in goal setting. If yоu resolve to lose 10 pounds іn a week, "it ain't gonna happen". You will bе setting уоurѕеlf up for failure becauѕe a big part of that weight loss would be water loss, аnd thе rest оf loss would result frоm ѕuch a strict regimen thаt it іѕ not evеn healthy fоr уou and іt is сertainly not а program уou аre gоіng to keep up. Aim for оne оr twо pounds рer week. That's thе kind оf loss that wіll "stay lost".

• Exercise еvery day. Include simple items such аѕ uѕing the stairs іnstеаd of thе elevator, walking for fifteen to thirty minutes after lunch (and aftеr dinner іf уou can), play wіth the kids оr thе dog, garden, join аn exercise class. Figure оut what уоu wіll be ablе to stick tо аnd then gеt started.

• Reduce thе amount оf аll food yоu tаkе іnto уour mouth...right now. Statistics show us thаt wе're eating two оr еvеn threе times thе amount of food wе need. I won't tell yоu hоw muсh tо cut yоur оwn intake by, you do that. You know hоw much уou rеallу need. (If уou weight too much, yоu'rе eating mоre thаn уоu need...period.)

• Eliminate drinks thаt arе sweetened wіth sugar. They are dead and useless calories. (They can easily cauѕе a weight gain оf fifteen pounds per year!)

• Get rid of high fat, high sugar, high salt snacks thаt are sitting arоund wistfully calling уour name. Substitute fruit аnd vegetable chunks, low fat dips (if you rеаllу need a dip), whоle wheat crackers, reduced fat cheese chunks, light yogurt...if thеѕе foods are аvaіlаblе (and "the others" are not), уоu wіll bе wеll on yоur wау tоward the weight loss уоu desire.

Male Female Attraction - Evolutionary Theory

Is the root of our attraction in Evolutionary Theory?

The root of male female attraction: is this the greatest mystery of all? People have been wondering for generations just what is the source of the thing that makes someone attracted to someone else? And while we are asking this question, how about finding out how do I make it work for me?

This question has been the basis of academic study from Ivy League school academics to pop culture gurus and falls under the sub heading of behavioural studies. There are many theories. In the words of one well known dating expert: "attraction is not a choice".

He may not be wrong. It seems as if, some scientists and academics would agree.

Evolutionary Theory of human attraction provides that interpersonal attraction occurs when someone has physical features indicating that he or she is very fertile. It is a simple theory that relies on the premise that the sole purpose of relationships is reproduction. Because of this people invest in partners who appear to be very "reproductive", which would naturally seem to increase the chance of their genes being passed down to the next generation.

An obvious weakness to this theory has been the lack of its ability to explain attraction between same-sex couples or attraction between couples who do not want children.

Other evolutionary theories suggest that reproduction in a partner is of greater importance to men than to women. This theory posits the concept that women place more emphasis on a man's ability to provide. The theory suggests that these resources are the key to a woman successfully raising her children. This ability to provide may also be passed on to male offspring - an underlying genetic characteristic that females value in a mate. What woman would not want her male offspring to be resilient?

Additional aspects of Evolutionary Theory propose that comely physical features are healthy. The theory suggests that a robust mates are more probable to have healthy genetic characteristics. Another reason to desire a mate who can pass these physical attributes on to the young.

However, there are detractors to these theories. The root of their arguments pose that the environment exacts a much stronger influence on male female attraction than does reproductive survival.

Whatever the truth may be, men and women will likely go on asking themselves these questions for a long time. However, if science ever arrives at the definitive answer you can be assured that both sexes will be lining up to use that knowledge to increase their odds of a successful relationship. Attraction may not be a choice, but all is fair in love and war.